Wright, Sarah S. MA; Lea, C. Suzanne PhD; Holloman, Roxanne MA; Cornett, Amanda MPH; Harrison, Lisa Macon MPH; Randolph, Greg D. MD, MPH
Quality Improvement (QI) methods, derived from industrial settings, have been successfully implemented in hospitals and health care agencies to enhance patient satisfaction and improve outcomes.1 Public health organizations are beginning to adapt QI methods to improve organizational performance and ultimately improve health outcomes in local communities.
In 2009, the North Carolina (NC) Public Health Foundation and the NC Division of Public Health, with financial support from local foundations, created the Center for Public Health Quality (CPHQ), a statewide resource devoted to building capacity for QI in the public health workforce. The CPHQ developed a 6-month training program adapted from the NC Area Health Education Center and NC Hospital Association's training program (which is based on the Institute for Healthcare Improvement's Breakthrough Series Collaborative model). A description of the NC QI training program is provided by Cornett and colleagues in this issue.2 The essence of the training provided an opportunity for local health department (LHD) teams to learn QI methods by applying tools acquired through workshops and conference calls to an actual project identified by the LHD staff. Beaufort County Health Department (BCHD) was one of the initial 4 LHDs in North Carolina to pilot test the training program in 2009, referred to as “Public Health QI 101” (QI 101). The BCHD identified promotion of breast-feeding in their Women, Infants and Children (WIC) supplemental nutrition program, a federal nutrition program for infants, children, and breast-feeding mothers, as the project to test implementation of the QI curriculum. The WIC offers healthy foods, including infant formula, nutrition education, breast-feeding education, and referral to other social support services.
Beaufort County, North Carolina, population 46 414 (2008), is a sparsely populated county in eastern North Carolina where 26% of the children live in poverty and the high school graduation rate is 65%.3 Rates of breast-feeding are lower in the WIC population than among all NC mothers.4 Among the approximately 84 000 average annual WIC recipients in North Carolina, 2008–2010, 55% of clients statewide reported initiating breast-feeding, with 17% breast-feeding at 6 months. In Beaufort County, North Carolina, of 1380 infants on WIC between 2006 and 2008, 48% were ever breast-fed and 15% were breast-feeding at 6 months.5 A recent study conducted among women in rural areas of North Carolina and Pennsylvania found that receipt of WIC was one of the factors associated with women discontinuing breast-feeding.6
This case study describes implementing QI 101 curriculum in an LHD using breast-feeding promotion as the project. Before introducing the QI 101 curriculum, BCHD staff did not have processes or procedures in place to sustain QI. The University and Medical Center institutional review board of East Carolina University determined that activity conducted for this project was outside the jurisdiction for human subjects research (UMCIRB 11-0292).
The QI breast-feeding project came about from a request for NC county health departments to volunteer to pilot test a health care QI training program that had been adapted for use in local public health. The BCHD was specifically encouraged to participate due to its previous success using a QI method where teams learned how to improve a process by reducing waste.7 As one of the 4 pilot health departments, the BCHD team members participated in the training program, provided feedback on the effectiveness of the training program, and advised how to adapt the program for local public health. The BCHD QI team was composed of the Health Director, a WIC nutritionist, the business officer, the maternity care coordinator, and the public health education specialist, who was the QI Team Leader. Maternity care coordination provides prenatal care checkups and counseling. This team was selected for their understanding of the issue, the ability to initiate changes in the health department, and their multidisciplinary perspectives.
Improving the continuity and coordination of services between the WIC and the maternity clinic was originally chosen as the focus of the project. However, following instruction provided in the QI 101 training program, including information on using the Model for Improvement (MFI) and Plan-Do-Study-Act (PDSA) cycles, the team recognized a narrower focus to improve the overall physical environment supporting breast-feeding was the best choice for a short-term project. The MFI incorporates a QI tool called a PDSA cycle, which allows staff to test and adapt change ideas on a small scale.8 It was the team's view that working on making the overall physical environment of the WIC unit more breast-feeding friendly would also involve staff in the prenatal clinic area, thus improving staffs' knowledge and promotion of breast-feeding across 2 departments. Once improving the breast-feeding environment was established as the project goal, the BCHD team decided the loci of the project would be breast-feeding education, promotion, and support.
Quality Improvement Training
The QI pilot curriculum consisted of one informational conference call followed by two 2-day face-to-face workshops. A 4-month “action period” served as the project testing and implementation phase where CPHQ staff, assigned to the BCHD QI team, provided on-site review, consultation, and coaching via conference calls. The team tested change ideas in their QI plan using PDSA cycles. Cornett and colleagues describe the QI 101 Course in another article in this issue. At the end of the 6-month timeline, the 4 teams involved in the curriculum pilot test attended workshops facilitated by experienced public health and health care QI experts to share successes and lessons learned.
The QI team leader served as the champion to move forward, empowering others to participate in decision-making and change. The QI team designed their implementation schedule within the broad timeline outlined in the QI 101 curriculum. Weekly meetings during the action period maintained feedback to the QI team.8
Identifying Change Ideas for Improvement
Pregnant women are referred to both the BCHD WIC program and prenatal clinic, where educational information about breast-feeding is provided. Choosing to breast-feed is a complicated behavior influenced by many factors, and the BCHD team knew that a varied perspective was needed to understand the issue. Several approaches were employed to ensure that a holistic view of breast-feeding was conveyed, including barriers and approaches to breast-feeding within the health department and within the WIC setting. Six key health department providers (midwife, nurse practitioner, senior maternity nurse, social worker, and 2 additional nurses) completed a self-administered survey with open-ended questions on their views about many of the QI project's intended goals, curriculum content, and improvements. This included opinions on:
* Breast Is Best, an introductory, voluntary, breast-feeding education class developed by the BCHD staff, offered weekly, and led by a WIC nutritionist to provide general breast-feeding education for mothers that may be interested in breast-feeding;
* need for follow-up reminder phone calls with newly breast-feeding mothers; and
* mother's opinion on current breast-feeding promotion being carried out in the health department at the time.
In addition, 4 mothers were interviewed face to face to gain their opinion on:
* factors that helped mothers initiate and maintain breast-feeding successfully;
* issues mothers believed should be covered in Breast Is Best; and
* current level of awareness of the new WIC food packages, which were to be implemented in fall 2009.
Interviews were also conducted with the WIC regional nutrition consultant, supported by the state WIC office for reviewing program performance, and the local hospital's lactation consultant for their perspectives on how to reach and educate clients about breast-feeding. With feedback gathered from the surveys and interviews, the team was able to obtain valuable information on factors that inhibit and promote breast-feeding; key topics that should be included in Breast Is Best; incentive items that mothers may find enticing; and how to go about creating a supportive environment. Based on 6 respondents, Table 1 summarizes provider recommended improvements to breast-feeding curriculum and education. The BCHD providers agreed that former clients should be surveyed on breast-feeding initiation and adherence. Extending awareness to health care providers outside the BCHD regarding WIC breast-feeding education was also seen as important.
Testing and Implementing Change Ideas
Delivery of educational messages
With the feedback gained from providers, clients, practitioners, and mothers, the team set about improving the delivery of educational messages related to breast-feeding. The team focused on improving attendance in the Breast Is Best educational sessions because these sessions were the primary venue for communicating the benefits of breast-feeding. An incentive bag was developed for all attendees and displayed in both the WIC office and prenatal clinic. The cooler-style bag included a water bottle with information on staying hydrated, a baby blanket for breast-feeding privacy, and a reminder bracelet to help mothers remember the next breast to be used for feeding. Bags were provided at completion of class. Funds provided from CPHQ were used to purchase the bags. Since 2009, approximately, 100 incentive bags have been distributed from the health department. In addition, in an effort to expose clients to breast-feeding messages during visits for prenatal services, an in-depth DVD on breast-feeding is being played in the prenatal waiting room.
Support for breast-feeding mothers
The primary way the BCHD QI team changed support for breast-feeding mothers was to ensure that the environment promotes and encourages breast-feeding. The BCHD team found it important to demonstrate to expecting mothers that breast-feeding is considered a priority.
Using feedback from client surveys, the team remodeled the WIC breast-feeding room (see the Figure for before and after photos). Remodeling the breast-feeding room took 3.5 months to complete, requiring coordination, approval for purchase, and ordering of materials related to artistry for the walls, new gliders, a television with DVD player, and more. The result was a brighter, warmer space more conducive to mothers who are breast-feeding while visiting the WIC program. To maximize space utilization, the newly designed and equipped breast-feeding room also is used for Breast Is Best sessions, enrollment of all breast-feeding babies, and breast pump distribution. Breast-feeding mothers are encouraged to use the room when visiting Maternity Care Coordination or WIC services.
FIGURE . Breast-feed...Image Tools
A second approach to creating an environment that complemented the educational messages was widespread promotion of new WIC food packages. Beginning in October 2009, the WIC program introduced new client food packages that offered more food to breast-feeding mothers and babies. Posters of side-by-side comparisons of the 3 food packages were created to highlight the large differences in food quantity based on breast-feeding choice. These posters were displayed in the WIC area and in the prenatal clinic waiting areas for maximum viewing opportunity and were also created as handouts for nutritionists working with clients.
Third, the BCHD team tested and implemented a system for follow-up phone calls to new breast-feeding mothers. Four of 5 providers agreed that contact within 72 hours after birth was important, although many disadvantages were noted (Table 1). However, providers agreed that a better system of birth notification from the local hospital would enhance outreach. A process to test follow-up calls was implemented using PDSA cycles. A worksheet outlining PSDA steps was completed for each of 3 cycles to test and obtain feedback by calling 3 to 4 new mothers about breast-feeding support. Using PDSA cycles resulted in a new process for a WIC nutritionist to contact new breast-feeding mothers, soliciting questions and offering support. Table 2 lists the objectives and PDSA steps across the 3 cycles to learn the mother's perspective of follow-up phone calls.
Breast-feeding mothers now have greater opportunity to request specific breast-feeding support appointments, in addition to the Breast Is Best course, with social workers and prenatal staff. A part-time breast-feeding peer counselor was hired. A bulletin board with mother and baby photos has generated interest of other mothers. Table 3 summarizes improvement ideas collected, tested, and implemented across the QI project.
Numerous forces are promoting the incorporation of QI into LHD settings, yet a paucity of information is published on the feasibility and success of QI in practice. This case study described a pilot test of QI curriculum adapted from the health care setting that utilized the MFI using PDSA cycles. The BCHD implemented a project that enhanced breast-feeding opportunities and education for expecting and new mothers by coordinating breast-feeding education and training with maternity care and WIC services based on data collected from both staff and clients. A nurturing environment for breast-feeding within the health department was created by renovating an existing room. Educational programs and messages were improved, appointments and follow-up for clients were expanded, and incentives for breast-feeding were highlighted.
Although the implementation of the curriculum did not include a pre- and postmeasurement component, data were collected throughout the length of the project and after completion. Breast-feeding data since project completion in October 2009 showed a 17% absolute increase in postpartum mothers engaging in breast-feeding in 2010. Of 205 postpartum mothers attending BCHD clinics in January 2010, 65 were breast-feeding (32%). Of 231 postpartum mothers in December 2010, 113 mothers were breast-feeding (49%). These data include both partial and exclusive breast-feeding.
Few published studies have described the QI processes implemented using the MFI or other QI frameworks at the county or LHD level. In 2008, the National Association of County and City Health Officials conducted a survey to identify the current status of QI in LHDs.9 Approximately, 51% of LHDs reported using PDSA cycles as QI tools during the previous year, and 56% focused on customer satisfaction as a performance area.9 However, no data were available on specific breast-feeding improvement projects in the National Association of County and City Health Officials report. The Los Angeles County Health Department has described population goals and performance measures for QI; however, breast-feeding indicators were not specifically identified.10 Mason and colleagues11 describe a process for establishing QI indicators in the Tacoma-Pierce County Health Department in Washington State, focusing on low birth weight, chlamydial infection, and adult obesity. The MFI, which includes the use of rapid testing using PDSA cycles, is being utilized across many public health departments, and wider dissemination of objectives, measurement indicators, and sustainable results are needed to more fully characterize the impact of QI in public health outcomes at the state and local levels.
From this QI breast-feeding project in the BCHD, the team and other staff involved learned the importance of team building and teamwork in QI. Using PDSA cycles to test small changes and make adjustments to processes before initiating larger-scale implementation allowed staff impacted by change to participate and contribute to the process, enhancing sustainability. For example, PDSA cycles were used to create a procedure for the WIC nutritionist to telephone new mothers to come in for breast-feeding consultation.
Staff buy-in was found to be one of the key components to making the project successful. If staff, both on and off the team, particularly management, does not see the value in a project that is likely to result in process modifications, then positive change is difficult and may not be sustainable. The team quickly learned that staff members who will be impacted by the project should be involved in planning and implementation from the beginning. This should include updates on the project's progress; notice for changes that will be implemented in the near future; involvement in the planning of changes and in opinions on how to improve; and roles in the new processes. In addition, success in one QI project can feed into other staff-initiated QI projects to create a culture of continuous QI.
Because this project was designed as part of testing newly developed QI curriculum for LHDs, objectives to measure and quantify change in breast-feeding rates, a long-term outcome, were not included. The primary objective of the breast-feeding promotion project was to provide a context in which to pilot test the QI 101 curriculum. In the process of testing the curriculum, which included implementing an actual project, significant improvements in the prenatal clinic and WIC programs were made to promote breast-feeding. Future QI projects at BCHD will have more explicit project-specific outcome measures that are tracked before, during, and after the project's implementation. Use of the QI 101 curriculum revealed options for problem solving by engaging frontline staff in identifying, planning, and implementing solutions. Promoting and sustaining breast-feeding remains the public health goal.
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11. Mason M, Schmidt R, Gizzi C, Ramsey S. Taking improvement action based on performance results: Washington State's experience. J Public Health Manag Pract. 2010;16:24–31.
breast-feeding; case study; curriculum development; North Carolina; quality improvement
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